intake-form | Stillpoint Somatic Therapies LLC

First name

Last name

Phone

Birthday

Month

Day

Year

Mailing Address

Referred By:

Please list any medications you are currently prescribed. Include the name and dosage, what the medication does, and any side effects. Please note any significant use of recreational drugs or alcohol.

Do you have any allergies or sensitivities?

Please list any major illnesses, accidents, or surgeries. (Please include reasons, recovery timeline, complications, and anesthesia)

Is there anything else you feel is important for me to know about you?

What is the primary goal or reason(s) for your visit?

Consent Agreement

I understand that bodywork should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor, psychotherapist, or other qualified medical specialist for any mental or physical ailment of which I am aware.

I understand that bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such.

Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep my practitioner Pamela updated as to any changes in my medical profile and understand that there shall be no liability on Pamela's part should I fail to do so.

Understanding all of this, I give my consent to receive care.

Client Signature HERE:

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I affirm that I have read the above consent form.

I am BELOW the age of 18.